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Anterior open-bite treatment with bonded vs conventional lingual spurs: A

comparative study

Article  in  American Journal of Orthodontics and Dentofacial Orthopedics · June 2016

DOI: 10.1016/j.ajodo.2015.11.026

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ORIGINAL ARTICLE

Anterior open-bite treatment with bonded vs

conventional lingual spurs: A comparative study
Luiz Filiphe Gonçalves Canuto,a Guilherme Janson,b Niedje Siqueira de Lima,c Renato Rodrigues de Almeida,d
and Rodrigo Hermont Cançadoe
Recife, Pernambuco, Bauru, S~ao Paulo, and Maringa, Paran
a, Brazil

Introduction: The purpose of this study was to compare the isolated effects of bonded and conventional spurs
on the craniofacial and dentoalveolar complexes of patients in the mixed dentition with anterior open bite.
Methods: The sample included 68 subjects with anterior open bite and Class I malocclusion. Group 1 comprised
20 patients treated with bonded lingual spurs with a mean initial age of 9.31 years (SD, 1.17). Group 2 consisted
of 21 patients treated with conventional lingual spurs with a mean initial age of 9.22 years (SD, 1.62). The control
group (group 3) consisted of 27 untreated subjects. One-way analysis of variance tests followed by Tukey tests
were used for intergroup cephalometric comparisons. After 1 month of treatment, patient acceptance of the spurs
was evaluated with a questionnaire. Results: There were significantly greater overbite increases in the exper-
imental groups than in the control group. The group with bonded lingual spurs showed significantly better accep-
tance than did the group with conventional lingual spurs during chewing and eating. Conclusions: The 2
appliances resulted in similar overbite increases during early open-bite treatment. After a week or less of
treatment, 92.5% of the children had adjusted to the spurs. (Am J Orthod Dentofacial Orthop 2016;149:847-55)

A
nterior open bite is a common malocclusion in
growing patients. The incidence of anterior
open bite varies with age1 and has a high prev-
alence (17.7%) in the mixed dentition.2,3 The etiology is
multifactorial, including oral habits, abnormal size or
function of the tongue, oral breathing, vertical growth
pattern, and congenital or acquired diseases.4 Among
the most frequent habits are finger sucking, pacifiers,
altered labial postures, and tongue habits.5
Treatment of an anterior open bite is a great chal-
lenge in orthodontics. After treatment, patients can
benefit from an improved ability to incise and chew
a
Professor, Department of Orthodontics, Uninassau Dental School, Recife,
Pernambuco, Brazil.
b
Professor and head, Department of Orthodontics, Bauru Dental School, Univer-
sity of S~ao Paulo, Bauru, S~ao Paulo, Brazil.
c
Professor, Department of Orthodontics, Federal University of Pernambuco,
Recife, Pernambuco, Brazil.
d
Assistant professor, Department of Orthodontics, Bauru Dental School, Univer-
sity of S~ao Paulo, Bauru, S~ao Paulo, Brazil.
e
Professor, Department of Orthodontics, Inga Dental School, Maringa, Parana,
Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Luiz Filiphe Gonçalves Canuto, Department of
Orthodontics, Uninassau Dental School, R. Joaquim Nabuco, 778, Recife, Per-
nambuco, 52011-220, Brazil; e-mail, luizfiliphecanuto@yahoo.com.br.
Submitted, July 2015; revised and accepted, November 2015.
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.11.026
food, and improved esthetics and speech. Several early
approaches to treat anterior open bite have been devel-
oped. Frequently, early anterior open-bite treatment is
performed with fixed and removable palatal cribs and
lingual spurs that may be associated with a chincup or
high-pull headgear in patients with a vertical facial
pattern.6-9 Although many treatment modalities are
available, the effectiveness and the stability after
treatment are still critical issues because evidence on
the long-term stability of these options is lacking.8-10
Investigators have cited tongue position or activity as
reasons for difficulty in achieving long-term stability of
anterior open-bite treatment.9,11 It was concluded that
banded-spur appliances correct anterior tongue posture
and maintain long-term stability of open-bite correction.
Lingual-spur therapy results in closure of the anterior
open bite by successfully keeping tongue pressure away
from the anterior teeth and serving as a reminder to the
patient to discontinue oral habits. Spur appliance effects
include palatal tipping of the maxillary incisors, increases
in overbite, and increases in dentoalveolar development
of the maxillary and mandibular incisors.6,9 Also, when
associated with a chincup, they can lead to a significant
decrease of the gonial angle.6 However, some clinicians
are wary of using banded spur appliances because of ex-
pected negative patient or parent reactions. The use of
this appliance has faced resistance from patients, par-
ents, speech pathologists, and psychologists, as well as
847
848
from some orthodontists.12 This aversion is linked to the
idea that this orthodontic device is a source of irritation,
generates discomfort, violates the patients' space, and is
not well tolerated by patients and parents.12,13 However,
recent studies have shown that treatment with banded or
bonded spurs was well accepted by patients and parents
and that their reactions to treatment seemed to be similar
to or even better than other functional and fixed
orthodontic appliances.6,12
Bonded lingual spurs (BLS) were envisioned and de-
signed based on the principles of conventional ortho-
dontic spurs. This appliance has some apparent
advantages, such as small size, low cost, esthetics, no
laboratory preparation, easy installation, and reduced
clinical time for bonding. However, we are aware of
only 2 studies that analyzed the effects of the bonded
spur appliance in growing patients with anterior open
bite.6,14 Despite favorable arguments about
effectiveness of BLS in early correction of anterior
open bite, their effects have not yet been compared
with conventional spurs. Therefore, the purpose of this
study was to compare the isolated effects of bonded
and conventional spurs on the craniofacial and
dentoalveolar complexes of patients in the mixed
dentition with anterior open bite.
MATERIAL AND METHODS
Ethical approval for this multicenter randomized trial
was obtained from the research ethics committee of the
Federal University of Pernambuco. Written and verbal
explanations about the study were provided to the pa-
tients' guardians. Those agreeing to participate
completed a written consent form.
The sample size of each group was calculated based
on an alpha significance level of 0.05 and a beta of
0.2 to achieve power of 80% to detect a mean difference
of 2.0 mm in overbite change between the groups, with
an estimated standard deviation of 1.69 mm, according
to Cassis et al.6 The sample size calculation showed that
21 patients in each group were needed. The sample sizes
of this study comprised at least 20 patients in each
group.
To obtain patients for the 2 experimental groups, 1
operator (L.F.G.C.) examined 1124 schoolchildren in
Recife, Brazil, with written authorizations from their par-
ents and school supervisors. The subjects were consecu-
tively selected according to the following criteria:
between 6 and 11 years of age with Angle Class I maloc-
clusions, anterior open bite equal to or greater than
1 mm, and maxillary and mandibular permanent central
incisors fully erupted. Patients with an anterior open
bite of at least 1 mm, without other occlusal changes,
June 2016  Vol 149  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Canuto et al
were invited to participate. None of the selected patients,
according to all sample selection criteria, refused to
participate after a detailed treatment explanation.
Full eruption in young children is difficult to deter-
mine. Therefore, children in the first transitional period
were considered to be eligible for treatment when the
maxillary lateral incisors were beginning to erupt and
the maxillary central incisors still showed an open bite.
Additionally, all patients had at least 1 oral habit, such
as tongue thrust or thumb or digital sucking, at treat-
ment onset. Children with tooth agenesis, loss of perma-
nent teeth, crowding, maxillary constriction, or posterior
crossbites were excluded from this study.
The selected patients were randomly allocated to 2
groups with different treatment protocols: BLS and con-
ventional lingual spurs (CLS). The 2 experimental groups
of the study were prospectively treated by 1 investigator
(L.F.G.C.) at the orthodontic department of the Federal
University of Pernambuco. The control group data were
obtained from the files of the orthodontic department
of the Bauru Dental School, University of S~ao Paulo.
Group 1 consisted of the initial and final lateral head-
films of 20 patients (10 girls, 10 boys) treated with BLS.
Each subject had an Angle Class I malocclusion, and the
initial mean anterior open bite was 4.01 mm (SD, 2.52).
The initial mean age was 9.31 years (SD, 1.17).
The protocol used in this group consisted of therapy
with BLS (Tongue Tamers; Ortho Technology, Tampa,
Fla) for 12 months. These appliances were bonded on
the palatal and lingual surfaces of the maxillary and
mandibular incisors with Concise Orthodontic Chemical
Curing Adhesive (3M Unitek, Monrovia, Calif). The
bonded spurs were sharpened with a carborundum
disk before installation, according to the methods of
Haryett et al15 and Justus.9,16 The bonded spurs were
positioned in the cervical and incisal portions of the
maxillary and mandibular incisors, respectively, to
prevent possible future occlusal interferences (Fig 1, A).
Group 2 consisted of the initial and final lateral head-
films of 21 patients (12 female; 9 male) treated with CLS.
Each subject had an Angle Class I malocclusion, and the
initial mean anterior open bite was 3.03 mm (SD, 1.37).
The initial mean age was 9.22 years (SD, 1.62).
The protocol used in this group consisted of therapy
with CLS for 12 months. The spur appliance was con-
structed from 0.045-in stainless steel wire to which 8
short, sharpened 0.026-in spurs, 3 mm in length, were
soldered to the anterior part. The spurs were positioned
3 mm from the cingula of the maxillary incisors and were
directed at an angle (downward and backward) to
encourage correct tongue posture, with the tip of the
tongue behind the maxillary central incisor papilla. The
spur appliance was soldered to maxillary molar bands
Canuto et al 849

Fig 1. A, Bonded lingual spurs; B, conventional (banded) lingual spur.

and cemented with Multi-Cure Glass Ionomer Band

Table I. Intergroup comparability evaluation (1-way
Cement (3M Unitek).9 The spurs were also sharpened
ANOVA)
with a carborundum disk before installation (Fig 1, B).
Radiographs of the 2 experimental groups were taken BLS group CLS group Control group
after the 12-month treatment period, within 30 days af- (n 5 20) (n 5 21) (n 5 27)
ter appliance removal. Variable Mean SD Mean SD Mean SD P
The control group (group 3) consisted of 27 un- Initial age (y) 9.31 1.17 9.22 1.62 8.5 1.12 0.0648
treated subjects with an Angle Class I malocclusion Initial overbite 4.01 2.52 3.04 1.37 3.35 1.92 0.2717
and an initial mean anterior open bite of 3.30 mm, ob- (mm)
Treatment/ 1.06 0.06 1.08 0.07 1.06 0.1 0.5133
tained from the files of the orthodontic department at
observation
Bauru Dental School, University of S~ao Paulo. This time (y)
sample had no treatment and was previously selected ac- SN.GoGn ( ) 36.25 3.63 35.38 3.36 33.42 5.63 0.0895
cording to the same criteria as above. The cephalometric FMA ( ) 29.05 5.08 29.75 3.63 29.57 5.59 0.8925
data were obtained from lateral headfilms at a compara- SN.PP ( ) 0.63 2.5 0.47 2.8 1.68 3.14 0.3216
Y-axis ( ) 69.55 2.58 68.94 2.48 67.46 3.98 0.0751
ble time period as the experimental groups, for the con-
trol group, as seen in Table I. The control group had been
selected for previous studies regarding early open-bite errors were calculated according to Dahlberg's formula18
treatment and was used here as well.6,7 (Se2 5 Sd2/2n), where Se2 is the error variance, and d is
The 3 groups were at stage 1 of cervical vertebrae the difference between the 2 determinations of the same
maturation, which is the period before the peak in skel- variable. The systematic errors were calculated with
etal maturity, according to Baccetti et al.17 dependent t tests, at P \0.05.19
All landmarks were identified and digitized by 1
investigator (L.F.G.C.) using Dolphin Imaging Software Statistical analyses
(version 10.5; Dolphin Imaging and Management Solu- Data distribution was analyzed with Kolmogorov-
tions, Chatsworth, Calif). These data were stored in a Smirnov tests. The pretreatment cephalometric charac-
computer, and the software corrected the image magni- teristics, and the treatment and normal growth changes
fication factor of the control group, which was 9.5%. were normally distributed in the groups and therefore
The experimental groups had digital lateral radiographs were compared using 1-way analysis of variance (AN-
taken; therefore, no magnification factor correction was OVA), followed by Tukey tests.
necessary. The radiographs were traced in random order Intergroup comparability regarding initial ages, ante-
by 1 operator (L.F.G.C.) to reduce bias (Figs 2 and 3). rior open-bite severity, observation period, and craniofa-
After 1 month of treatment, patient acceptance of cial growth pattern were evaluated with ANOVA. The
the spurs was evaluated with a questionnaire, similar chi-square test was used to compare sex distributions
to that proposed by McRae.14 The questionnaire con- in the groups.
sisted of questions on patient reactions during speaking, Treatment and normal growth changes were calcu-
chewing, and eating, discomfort to the tongue, and how lated by subtracting the initial from the final values.
long it took to adjust to the spur therapy (Fig 4). Means and standard deviations were calculated for the
Within a month from the first measurement, 20 digi- treatment and normal growth changes in all variables.
tized lateral radiographs were randomly selected and re- Intergroup treatment and normal growth changes were
measured by the same examiner (L.F.G.C.). The random compared using ANOVA, followed by Tukey tests.

American Journal of Orthodontics and Dentofacial Orthopedics June 2016  Vol 149  Issue 6
850
Fig 2. Cephalometric points: S, sella; N, nasion; Po, po-
rion; A, subspinale; B, supramentale; Pog, pogonion; Or,
orbitale; Me, menton; Go, gonion; Gn, gnathion; ANS,
anterior nasal spine; PNS, posterior nasal spine; UIE, up-
per incisor edge; UIA, upper incisor apex; LIE, lower
incisor edge; LIA, lower incisor apex; UMT, mesiobuccal
cusp of the maxillary first molar; LMT, mesiobuccal cusp
of the mandibular first molar.
Chi-square tests were used to compare the accept-
ability of conventional vs bonded lingual spur treat-
ments.
All statistical analyses were performed with Statistica
software (version 7.0; StatSoft, Tulsa, Okla). Results were
considered significant at P \0.05.
RESULTS
Linear random errors ranged from 0.08 (Mx1-PP) to
0.27 mm (overjet), and angular random errors ranged
from 0.15 (Md1.NB) to 2.0 (SN.GoGn). There were
no statistically significant systematic errors.
At the pretreatment stage, the groups were compara-
ble regarding age, anterior open-bite severity, observa-
tion period, craniofacial growth pattern, and sex
distribution (Tables I and II).
During treatment, there was a significantly greater
decrease in overjet in the BLS group compared with
the control group. There were significantly greater in-
creases in overbite in the BLS and CLS groups compared
with the control group (Table III).
The maxillary incisors had significantly greater
palatal tipping and vertical development in the experi-
mental groups than in the control group, but the maxil-
lary incisors had greater retrusion in the BLS group in
June 2016  Vol 149  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Canuto et al
Fig 3. Angular and linear measurements: 1, ANB angle;
2, overjet; 3, SN.GoGn angle (angle between S-N and
Go-Gn lines, or mandibular plane angle); 4, FMA (angle
between Frankfort and mandibular planes); 5, SN.PP
angle; 6, y-axis-NS.Gn angle (angle between N-S and
S-Gn lines); 7, LAFH: lower anterior face height (distance
between ANS and Me); 8, overbite (distance between the
incisal edges of the maxillary and mandibular central inci-
sors, perpendicular to the occlusal plane); 9, Mx1.NA
(angle between maxillary incisor long axis and NA line);
10, Mx1-NA (distance between the most anterior point
of the maxillary central incisor and the NA line; positive
value was assigned when the structure was anterior to
the line); 11, Mx1-PP (perpendicular distance between
the maxillary central incisor and the palatal plane); 12,
Mx-PP (perpendicular distance from the maxillary first
molar mesial point to the palatal plane); 13, Md.NB (angle
between the mandibular incisor long axis and the NB
line); 14, Md-NB (distance between the most anterior
point of the mandibular central incisor and the NB line; a
positive value was assigned when the structure was ante-
rior to the line); 15, Md-MP (perpendicular distance from
the mandibular incisor edge to the mandibular plane
GoMe); 16, Md6-MP (perpendicular distance from the
mandibular first molar mesial point to the mandibular
plane GoMe).
relation to the other groups. The maxillary molars had
greater vertical development in the CLS than in the other
groups (Table III).
The mandibular incisors had significantly greater
lingual tipping in the experimental groups than in the
control group (Table III).
Both appliances were well tolerated by patients, but
the BLS had significantly better acceptance than the
Canuto et al
Fig 4. Patient questionnaire.
Table II. Intergroup sex distribution comparability
evaluation at pretreatment (chi-square test)
Sex
Group Female Male Total
BLS 10 10 20
CLS 12 9 21
Control 22 5 27
Total 44 24 68
Chi-square 5 5.7471; df 5 2; P 5 0.0565.
CLS during chewing and eating. For both groups, the
discomfort time was at most 7 days in most patients
(Fig 5). Positive overbite was achieved in 16 of the 20
and 16 of the 21 subjects treated with the BLS and the
CLS, respectively, during the 12 months of treatment.
DISCUSSION
Initially, the groups were similar regarding several
parameters that could influence this comparison
(Tables I and II). In relation to the sample selection
criteria, it can be argued that an anterior open bite of
1 mm or more may not be an ideal malocclusion
severity for this study. However, anterior open bites of
at least 1 mm are frequent malocclusions that should
be intercepted in children with persistent oral habits.
Moreover, if during sample selection more severe
occlusal or cephalometric parameters had been
adopted, the sample size would have been negatively
affected. Negative overbite before treatment ranged
from 1.00 to 10.00 mm in the experimental
groups. Previous studies on this topic also used
samples with similar anterior open-bite severity at pre-
treatment.6,7,14,20-22 Despite not differentiating the
American Journal of Orthodontics and Dentofacial Orthopedics
851
patients between dental and skeletal open bites, no
significant intergroup difference was observed
regarding the craniofacial growth pattern at
pretreatment (Table I).
Initially, all patients had at least 1 oral habit, such as
tongue thrust, or thumb or digital sucking. Although
many factors may play a role in the etiology of anterior
open bite at an early age, thumb and dummy (pacifier)
sucking are the primary etiologic agents of anterior
open bite at this stage.23 Anterior tongue thrusting
and anterior tongue resting posture are always present,
in varying degrees, with an anterior open bite.24 Tongue
spurs are effective in eliminating the deleterious sucking
habits, tongue thrusting, and anterior tongue
posture.6,8,9,14,16,25 Therefore, the tongue spurs would
act on the most important causative factors of open
bite at this stage.
A vertical growth pattern is often associated with
anterior open bite.2 In these patients, dental compensa-
tions produced by conventional orthodontic treatment
might not lead to satisfactory outcomes, thus requiring
another treatment approach directed at vertical control
of facial growth.3,26,27 Chincup therapy is indicated by
some authors for vertical control of anterior open
bite.6,7,28-30 Because the patients in the evaluated
groups did not have excessive vertical facial patterns,
no major concern in controlling the vertical dimension
was necessary (Table I).
During the evaluation period, the control group
received no treatment. To prevent further detrimental
effects to these subjects, the period of this treatment
protocol was limited to 1 year, which seemed to be
ideal and agrees with other studies.6-8,31 After that,
all subjects of the control group had orthodontic
treatment.
June 2016  Vol 149  Issue 6
852 Canuto et al

Table III. Intergroup cephalometric comparisons of treatment changes with 1-way ANOVA and Tukey tests
BLS group (n 5 20) CLS group (n 5 21) Control group (n 5 27)

Variable Mean SD Mean SD Mean SD P

Dental relationships
Overjet (mm) 0.41A 0.77 0.25A,B 1.8 0.69B 1.07 0.0054*
Overbite (mm) 4.26A 3.1 3.41A 2.01 1.43B 1.36 0.0079*
Maxillomandibular relationship
ANB ( ) 0.55 1 0.8 1 0.11 1.41 0.0999
Vertical components
SN.GoGn ( ) 0.74 1.15 0.8 2.3 0.1 1.72 0.3853
FMA ( ) 1.17 2.86 0.23 2.07 1.09 2.81 0.4911
SN.PP ( ) 0.23 1.77 0.44 2.18 0.34 1.79 0.5022
Y-axis ( ) 0.23 0.82 0.51 2.4 0.14 1.7 0.7503
LAFH (mm) 0.45 1.74 0.88 1.61 0.91 1.39 0.5751
Maxillary dentoalveolar components
Mx1.NA ( ) 3.71A 4.97 1.58A 5.77 0.57B 3.62 0.0093*
Mx1-NA (mm) 0.74A 1.99 0.32B 1.78 0.71B 1.5 0.0169*
Mx1-PP (mm) 2.34A 1.48 2.25A 1.3 1.06B 0.77 0.0026*
Mx6-PP (mm) 0.61A 0.71 1.20B 0.83 0.64A 0.8 0.0438*
Mandibular dentoalveolar components
Md1.NB ( ) 1.73A 3.78 3.06A 3.24 0.66B 2.12 0.0259*
Md1-NB (mm) 0.19 0.97 0.21 0.7 0.27 0.63 0.0829
Md1-MP (mm) 1.84 0.83 1.91 0.83 1.39 0.86 0.1286
Md6-MP (mm) 0.48 0.76 0.48 0.91 0.44 0.80 0.9867

Different letters represent statistically significant differences.

*Statistically significant at P \0.05.

The overbite measuring technique used in this evalu-
ation is most frequently used in the literature and un-
doubtedly produces more consistent results because it
measures the distances between the maxillary and
mandibular incisor borders perpendicular to the
occlusal plane.20,21,32-34 There are no reported
differences in the results with different measuring
techniques because usually the same technique was
used in the treated and control groups.6,7,21,22,31,35,36
The significantly greater overjet decrease of the BLS
group in relation to the control group may be conse-
quent to the greater palatal tipping of the maxillary in-
cisors in relation to the mandibular incisors in the BLS
group, resulting from the lack of tongue pressure on
the incisors. Additionally, because the children in the
control group most likely continued with their sucking
habits, overjet tended to increase (Table III). Overjet in
the BLS group also decreased nonsignificantly more
than in the CLS group because the maxillary incisors
had greater palatal tipping than the lingual tipping of
the mandibular incisors; in the CLS group, the opposite
occurred. Therefore, these nonsignificant changes be-
tween these appliances should be further investigated.
There were significantly greater overbite increases in
the experimental groups than in the control group
(Table III). These changes were slightly smaller than
those observed in a previous study in which children
with anterior open bite received bonded spurs associated
with high-pull chincup therapy.6 However, as expected,
the changes in overbite observed in this study were more
evident than those in a study by McRae14 (11.38 mm) in
which older patients (the sample comprised children and
mainly adolescents) with anterior open bite received
bonded-spur therapy for only 6 months.
In our study, positive overbite was achieved in 16 of
the 20 and 16 of the 21 subjects treated with BLS and
CLS, respectively, during the 12 months of treatment.
Probably the failure in overbite correction in some sub-
jects was consequent to their persisting sucking habits,
anterior tongue thrusting, or posture. It could also
have been because the observation period was only
1 year and not long enough to correct the open bite in
some patients.6 Perhaps the spurs cannot eliminate these
habits in all patients. These issues should be further
investigated. Of the 27 subjects in the control group, 3
had spontaneous correction of their anterior open bite.
This is a usual finding in untreated patients with
open-bite malocclusion; this can occur when the patient
abandons the deleterious sucking habits and the
strength of tongue thrusting is not enough to maintain
the open bite.24,37-39
Treatment with these appliances could not cause
different changes from normal growth in the maxillo-
mandibular relationships and in the skeletal vertical

June 2016  Vol 149  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Canuto et al
Fig 5. Patient acceptance evaluation of the lingual spurs (chi-square tests).
components, probably because of the short period of
observation.
The maxillary incisors of the experimental groups
showed significantly greater palatal tipping than did
the control group (Mx1.NA), as previously reported.35
This might be consequent to the decrease or elimination
of tongue thrust, anterior tongue rest posture, and suck-
ing or lip habits, similarly encouraged by the bonded and
the conventional spurs.9,40
In the vertical plane, the experimental groups showed
more vertical dentoalveolar development of the maxil-
lary incisors (Mx1-PP) than did the control group.
Both spur appliances interrupted sucking and thrusting
habits and allowed normal vertical development in the
anterior region, causing the observed changes.5 More-
over, the spurs caused a change in the tongue's anterior
rest posture, which in turn allowed the incisors to erupt,
closing the anterior open bite. Additionally, wearing
spurs during orthodontic treatment of anterior open
bite improves posttreatment stability because it induces
a permanent modification of the tongue's anterior rest
posture.8,9,41
American Journal of Orthodontics and Dentofacial Orthopedics
853
Vertical dentoalveolar development of the maxillary
molars (Mx6-PP) in the CLS group was significant
greater than in the other groups. However, the differ-
ences in these changes between the BLS and CLS groups
did not imply significant changes in overbite correction
or other vertical component changes of the experimental
groups. Additional studies are necessary to elucidate
whether this is a usual effect when conventional spurs
are used.
Similar to the maxillary incisors, the mandibular inci-
sors of the experimental groups showed significantly
greater lingual tipping than did the control group
(Md1.NA), corroborating previous reports.25 This might
be consequent to the same myofunctional changes pre-
viously described for the maxillary component.
Our results showed that overbite correction was
achieved primarily by dentoalveolar effects. Therefore,
this demonstrates that early correction of open bite is
easier because it is usually primarily dental, and the
greater growth potential can help in the correction.6
Some clinicians recommend spur therapy to change
tongue behavior, close the open bite, and increase
June 2016  Vol 149  Issue 6
854
treatment stability.9,15,42 However, others are still
concerned about the reactions of patients and parents
to this orthodontic appliance.12,13 Results of the
comparative acceptance evaluation of conventional vs
bonded lingual spur therapies showed that both
appliances were well tolerated by patients (Fig 5). In
addition, the BLS group showed significantly better
acceptance than did the CLS group during chewing
and eating. Speech and chewing impairments were sig-
nificant in some patients; however, the discomfort
time was temporary and lasted up to 7 days in most pa-
tients (95% and 90% of the BLS and CLS patients,
respectively). These results clearly indicate that in chil-
dren, adaptation to both spur appliances tends to occur
in a short time. Studies regarding discomfort, pain, and
speech impairment of orthodontic appliances reported
that adaptation to new orthodontic appliances took be-
tween 7 and 14 days after insertion.43,44 Compared with
other appliances evaluated in these articles, such as
headgear and the bionator, the BLS and the CLS seem
to show less rejection by patients.12
Based on these results, it can be inferred that BLS and
CLS induced similar and favorable dentoalveolar
changes in children with anterior open bite. However,
some aspects should be considered in appliance selec-
tion. Bonded spurs tend to be more convenient in clin-
ical practices because they eliminate the banding
procedures and laboratory phases.
Despite the good effects of the bonded spurs, caution
is imperative in using them. Although the spurs were
rarely lost during the 12-month treatment period, they
can occasionally fall off and be aspirated into the lungs
or swallowed. This should also be considered during
appliance selection.
CONCLUSIONS
BLS and CLS produced similar overbite increases dur-
ing early open-bite treatment.
BLS had better acceptation during chewing and
eating. However, in both groups, 92.5% of the children
adjusted to the spurs after 1 week or less of treatment.
ACKNOWLEDGMENTS
We thank the Brazilian research funding agencies
(FACEPE and CNPq) for the grant DCR 0008-4.02/10.
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